Aligned TeleHealth, Inc. On-site Staffing & TelePsychiatry

Aligned TeleHealth, Inc. On-site Staffing & TelePsychiatry

Aligned s History Dr. Nitin Nanda, P.C. Founded in 2000 Founded as a Private Psychiatry Practice in Los Angeles by Dr. Nitin Nanda upon Completing Residency and Fellowship in Geropsychiatry at the University of California Los Angeles. Office and Community Based Practice in Hospitals, Skilled Nursing Facilities and Ambulatory Clinics. Asana Integrated Medical Group Founded in 2002 Expanded to a Hospitalist Group Practice Focusing on Facility Based Services. Developed a Distinct Telemedicine Division Providing Coverage to Hospitals. Expanded On-Site Services into Arizona and Telemedicine Services into Colorado and Montana. Aligned Telehealth Founded in 2013 Rebranded as a TelePsychiatry Medical Group Due to Demand and Rapid Growth in the TelePsych Sector. External Investment from a Los Angeles area Angel Investor External Investment from a $2 Billion Dollar Global Health Sciences Private Equity Firm. Continued Expansion of On-Site & TelePsychiatry Services. 2

Aligned s Services On-Site Services Psychiatric Hospitalist Post-Acute Coverage Outpatient Clinics Telemedicine Services Emergency Department Med-Surg Inpatients Acute Psych Inpatients Observation/CSU Post-Acute Facilities Outpatient Clinics Correctional Health Addiction Centers Patient Direct/Remote Care 3

Partnerships Acute Care Hospitals General Critical Access Behavioral Health Correctional Facilities Jails Prisons Physician Groups Medical Foundations HMO/Medical Group Clinics Specialty/Rural/FQHC Clinics Mental Health Treatment Facilities Addiction Recovery Centers Residential Treatment Centers Post-Acute Facilities Skilled Nursing Transitional Care Assisted Living Population Health Health Plans ACOs Aligned Contracts with a Number of Technology Companies, Intermediaries and Insurance Carriers Involved in Providing Psychiatric Services to Schools, Prisons and Health Plans. 4

Current Geographic Presence Alaska Hawaii 61 Acute Care Hospitals 52 Post-Acute Facilities 10 Outpatient Clinics 26 Prisons/Jails 5

Current Licensed States Alaska Hawaii 6

Aligned s Revenue Cycle Expertise Our Origins as a Hospitalist Group Required Developing Extensive Expertise in Professional Fee Billing We Can Performa All Pro-Cycle Billing for Our Clients We Offer RCM Services to ED Clients As a Direct Off-Set To Consultation Charges We Offer RCM Services to Ambulatory or Hospitalist Clients to Maximize Revenue and Minimize Required Stipends/Off-Sets Many Systems Struggle with Psychiatric Pro-Cycle Recovery Due to Limited Teams and a Belief that Revenues don t Offset Cycle Costs Some Systems Don t Bother to Bill at All for ED Consults, CL Consults or Other Potentially Recoverable Consultative Services 7

Active TelePsychiatry CPT Codes Distant Site Codes Medicaid All E&M and psychotherapy tele-based services must be billed with the GT modifier (dropped by Medicare in 2018) using POS 2: 1) 99201 99215 Office or other outpatient visit (new or established patient) 2) 99241 99255 Consultations: Office or other outpatient, initial or follow-up inpatient, and confirmatory 3) 90791 Psychiatric diagnostic evaluation 4) 90792 Psychiatric diagnostic evaluation with medical services 5) 90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services 6) 90832 Psychotherapy, 30 minutes with patient 7) 90837 Psychotherapy, 60 minutes with patient Originating Site Codes 1) Q3014 (Originating site Telehealth Facility Fee also allowed by Medicare) = $22.94 2) T1014 (Telehealth transmission costs incurred while providing tele services via audio/video, per minute recognized by Medicare but not reimbursable) = $0.24 Medicare: In addition to above-- 1) 96150 96150 Individual and group health and behavior assessment and intervention 2) Expanded psychotherapy codes 3) G-codes covering pharmacologic management, Smoking cessation services, SUD assessments and interventions, and Annual Wellness Visits 4) 99496-99498 Advanced Care Planning 1) G0502-G0504 (New 2018 Medicare only Collaborative Care Model codes billed by primary care clinics to allow for the cost of behavioral health professionals and care managers and/or social workers required under the care model. 2) Medicaid programs could adopt as pilots or under Waiver programs. 8

Professional Fee Reimbursement Medicare Qualifications The Originating Site Must Be In An Eligible Location: 1. In A County Outside of A Metropolitan Statistical Area (MSA) As Determined By The Census Bureau; 2. In A Rural Health Professional Shortage Area (HPSA) As Determined By HRSA; or 3. Entities Participating In a Federal Telemedicine Demonstration Project Approved By The Secretary Of The DHHS As Of 12/31/00. 4. Must Use An Interactive Audio And Video Telecommunications System That Permits Real-time Communication Between The Provider And The Distant Site. Asynchronous Store And Forward Is Only Permitted In Fed Demonstration Programs In Alaska And Hawaii. Originating sites may be any of the following: Physician or practitioner offices Hospitals CAHs Rural Health Clinics FQHCs Hospital - or CAH-based Renal Dialysis Centers SNFs Community Mental Health Center. Qualifying distant site providers: Physicians NPs/PAs Clinical Psychologists and Clinical Social Workers (cannot bill for psych diagnostic interview exams with medical services or medical E&M services 90792, 90833, 90836, and 90838) Nurse-midwives Clinical Nurse Specialists RD or nutrition professionals 9

Telepsychiatry Professional Fee Recovery in California FY 16-17 Carrier Average Payment Carrier Average Payment Carrier Average Payment Allied Physicians $121.60 Humana $145.28 SCAN Health Plan $147.48 Alpha Care $122.86 Inland Empire Health Plan $127.00 Seaside Health Plan $130.95 Alta Med Health $104.94 IEHP Medicaid $126.94 Seaside IPA $126.33 Angeles IPA $97.23 Inland Faculty Med Group $130.08 Secure Horizon CA PacifiCare $143.31 Arcadian Health Plan $143.50 Inland Valley (Redlands IPA) $93.47 TriCare for Life $148.62 Blue Cross of California $124.49 Kaiser Foundation Southern $146.43 United HealthCare $111.78 Blue Shield of California $187.50 Kaiser Foundation North West $175.89 Universal Care California $148.24 Brand New Day $148.98 LA Care $130.95 Vantage Medical Group $97.23 CA Health & Wellness $56.89 LaSalle Medical Associates $126.29 Veterans Administration $148.54 Caremore $147.48 Managed Health Network $135.59 ALL PAYER Caremore IPA $143.50 Medicare Northern California $103.73 AVERAGE PAYMENT CenCal Health $130.94 Medicare of CA $102.47 Cigna $91.27 Molina of California $129.05 Community Family Med Group $98.21 Pinnacle Claims Mgmt $130.95 EHS Medical Group $97.23 Preferred IPA $129.64 Employee Health Systems $125.01 PrimeCare Medical Network $143.50 Gold Coast Health Plan $148.89 Prospect Medical Group $130.95 Health Care LA IPA $96.19 Regal Medical Group $130.95 $117.86 E&M and G-Telemedicine Professional Fee Claims Recovered by Aligned Telehealth RCM Services Fiscal Year 16-17 10

Board Certified Psychiatrists Psychiatrists Licensed in 35 States Current Projects in 15 States Separate Providers for Telemedicine and On- Site Services No Crossover or Scheduling Conflicts. Physicians are 100% Board Certified Psychiatry Sub Specialties Include: Adult Child & Adolescent Geriatric Forensic Addition Psychosomatic Medicine Consultation Liaison Psychiatric Mental Health Nurse Practitioners Night Coverage Can Be Provided by US Licensed Providers Overseas 11

Telepsychiatry In Practice Acute Care Hospital ED Consults Inpatient Consults Acute Psych Rounding 1. ED Physician Initiates Consult Request Through Aligned Call Center 2. Credentialed TeleMedicine Psychiatrist Sees Incoming Consult Request on Their Smartphone App 3. Psychiatrist Accepts Consult Request Right Through Their App 4. Hospital Personnel Are Alerted That Physician Will Be Online Soon And Properly Position Telemedicine Cart or Appliance 5. Psychiatrist Provides Consult 6. Psychiatrist Discuses Findings and Recommendations with ED Team 7. Psychiatrist Completes Consult Documentation into Hospital's Health Record via Remote Connection 1. ED Physician Initiates Consult Request Through Aligned Call Center 2. Credentialed TeleMedicine Psychiatrist Sees Incoming Consult Request on Their Smartphone App 3. Psychiatrist Accepts Consult Request Right Through Their App 4. Hospital Personnel Are Alerted That Physician Will Be Online Soon And Properly Position Telemedicine Cart or Appliance 5. Psychiatrist Provides Consult 6. Psychiatrist Discuses Findings and Recommendations with Hospitalist/Internal Medicine Team 7. Psychiatrist Completes Consult Documentation into Hospital's Health Record via Remote Connection Response Times 1. Rounding Is Done On A Scheduled Basis With Defined Days And Shift Durations 2. Psychiatrist Is Live On Telemedicine Cart During The Entire Rounding Session 3. Nurse Rounds on Unit With Telemedicine Provider 4. Psychiatrist Enters Visit Notes & Orders Into Health Record 5. Psychiatrists Are Available To Consult With Other Physicians as Needed During Rounding Sessions or Via Telephone When Not Rounding (Subject To Availability). Outpatient Post-Acute 1. Telemedicine Visits Scheduled in Time Blocks Similar to On-Site Coverage Models 2. Clinic/Facility Personnel Setup Telemedicine Cart In Designated Exam Room or Move Cart To Patient Rooms. 3. On Site Facilitator rooms Patients & Provides Support to Psychiatrist Similar to a Doctor s Nurse 4. Psychiatrist Provides Patient Services 5. Documentation is Completed in a Health Record Immediately Following Patient Visit 60 Minutes or Less 120 Minutes or Less Depending As Scheduled As Scheduled 12

Aligned s Proprietary Technology Centralized Call Center Calls are Always Answered Live Consult Request Relayed to Call Center Staff TeleMedicine Scheduler Call Center Staff Relay Consult Request to Physician Portal Physicians Can See Consult Requests in Real Time on Their Smart Phones Number & Location of Pending Consults Time Patients Have Been Waiting Time Consults are Initiated Consult Time Documentation Time Consultation Close All Operational Metrics can Be Monitored in Real Time an Trend Reported Proprietary Technology Allows us To Provide Most Consults in 60 Minutes or Less & Adjust Coverage to Meet Response Times Obligations 13

6-Month Dashboard Example by Provider and Facility Confidential and Proprietary. 14

Aligned s Quality Process & Metrics Completely Customized to Each Partner Common ED Metrics Hold Utilization. Use of Physical/Chemical Restraints. Use of 1:1 Sitters. Discharge Rate to Community or Other Inpatient Units. BHU Hospital Admit Decision to ED Departure Time. Improvement in the percent of patients seen within 60 minutes of a telemedicine request. Timeliness of EMR documentation. Common On-Site/Hospitalist Metrics Medication Consents Completed Prior To Administration of First Dose Ensure Timely Monitoring & Adjustments of Patient s Legal Status Psychiatric Evaluation Completed Within 24 Hours Of Admission 100% Patients Discharged With Multiple Anti-psychotic Medications Have Documented Supervise Allied Health Providers as Appropriate & Assigned Timely And Appropriate Documentation Meets Regulatory & Medical Staff Requirements Policies And Procedures Governing Medical Record Documentation. Provide Necessary Concurrent Review Activities To Comply With Payer Claims Requirements. 15

Telemedicine Equipment Telemedicine Cart and Related Hardware Clients May Use Any Telemedicine Hardware Any Existing Carts Can Be Used By Aligned Providers Aligned Can Recommend Equipment Vendors If Necessary Carts Vary In Price, But Typically Cost Less About $5000 Less Sophisticated TeleMedicine Appliances are Less Costly Some Facilities Utilize Portable Tablets or Laptops It Is Usually Best To Have Separate Units For The ED And The Inpatient Floors. Telemedicine Software Clients May Use Any Telemedicine Software Platform Aligned Providers Will Be Trained To Utilize Client Software and Electronic Health Record If Needed, Aligned Can Provide A Software Platform (Usually at Zero Cost) 16

TelePsychiatry Pricing Models Service Location Emergency Department Inpatient Consults Acute Psych Rounding Post-Acute Outpatient Clinic Pricing and Coverage Models Per Encounter Rate (May Require Minimum Monthly Guarantee) Partner Claims and Retains Available Professional Fees* 24-7-365 Coverage by Board Certified Psychiatrists Response Times in Less than 60 Minutes Per Encounter Rate (May Require Minimum Monthly Guarantee) Services & Dedicated Panel Can be Combined with ED Services Can be Scheduled/Fixed Coverage is usually M-F Partner Claims and Retains Available Professional Fees* Scheduled Service Per Hour/Shift Cost Structure Psychiatrists Typically See 6-8 Patients in 4-Hours or 8-10 Patients in 6-Hours Partner Claims and Retains Available Professional Fees Varies Based on Location, Patient Population and Payer Mix Per Consult Rate, Per-Member-Per-Month or Other Rate Structures Available Consult Rate for Hospital Based/Affiliated SNFs, Priced at Medicare Rates Risk Based Pricing for Medicare Advantage or Concierge Plans Hourly Coverage Rate for Scheduled & Dedicated Clinic Hours Partner Claims and Retains Available Professional Fees* *Aligned Telehealth has its own billing service and is contracted with major behavioral health plans. We will work with the client to determine who should be doing the billing in order to receive optimal reimbursement to offset the per encounter and/or hourly coverage rates. 17

On-Site Services Aligned s Acute and Post-Acute Coverage Services Use a Coordinated Care Approach to Manage Acute Transitions to Post-Acute Care Ensuring Readmissions are Minimized Acute Care Hospitalist Post- Acute Coverage Manage Inpatient Units at General Acute Care Hospitals or Psychiatric Hospitals. Provide Psych Consultation Services to Med/Surg Patients. Emergency Department Coverage On-Site During Days with Telephone or TeleMedicine Coverage After-Hours Staffed by Board Certified Psychiatrists Requires Professional Services Contract Including Financial Support Stipend Psychiatric Consultation for Post-Acute Patient Primarily Staffed with Psychiatric Advanced Practice Registered Nurses/Nurse Practitioners Psychiatrist Oversight Professional Services Contract is Not Required Financial Support Stipend is Not Required for Basic Services 18

Implementation and Support Key Implementation Activities Policy/Procedure Review Bylaw Review Technical Review Provider/Personnel Training Trial Sessions Ongoing Support Services Clinical Leadership/Training Conducted via TeleMedicine by Vice-President of Medical Affairs Real-Time Response & Issue Monitoring by Operations Team Full Suite of Online Reports and Data Analysis Capability Available to Clients 19

Key Contacts Executive Vice President Business Development Miles D. Kramer, LCSW, CCHP mkramer@alignedth.com (970) 397-7683 Chairman & CEO Dr. Nitin Nanda nnanda@alignedth.com (818)-574-5751 Home Offices Aligned TeleHealth, Inc. 26135 Mureau Rd, Suite-101 Calabasas, CA 91302 info@alignedth.com (844)-496-9160 www.alignedth.com 20